Keywords

Introduction

Rates of psychiatric morbidity among young people have risen in most countries during the course of the COVID-19 pandemic (Organisation for Economic Co-operation and Development, 2021). At the same time, mental health services and support for young people have been heavily disrupted by the COVID-19 crisis. A World Health Organisation survey in June-August 2020 found that in more than three-quarters of countries globally school mental health programmes were completely or partially disrupted, while in over 70% of countries child and adolescent mental health services experienced disruptions (World Health Organisation, 2020). At the time of writing, data about the effect on demand for and delivery of specialist inpatient mental health services for young people are limited. One acute adolescent inpatient service in the United States reported a reduction in the number of referrals, but a modest increase in length of stay. Of diagnoses at admission, there was a significant increase only in substance use disorder (Ugueto & Zeni, 2021). Owing to the quaternary nature of the service delivered by the Walker Unit we did not anticipate, and have not observed, a change in the pattern of referrals to us. Adjustments required by the pandemic have, however, had a substantial impact on the service we provide.

The Walker Unit, like the rest of the Health Service, has undergone significant change with periods of increased restriction that have intensified with each subsequent outbreak of the disease. The Unit has applied successfully for exemption from some directives, such as the prohibition of consumer leave. We argued that consumer leave was an essential component of progression towards discharge (see Chap. 4). As the service devised standard operating procedures (SOPs) subject to reviews, constant updates based on the latest health advice from the ministry, we provided input into what could be implemented. It took some time for staff, patients and families to adjust to each rule change. We soon realised that clear communication, co-operation and compassion promoted compliance.

Ward Structure

Following the first COVID-19 outbreak in Australia in March 2020 the hospital management visited every ward to decide where suspected and confirmed cases would be isolated. The Unit Director and Nurse Unit Manager (NUM) were consulted about balancing patients’ needs against compliance with COVID-19 screening requirements. Following consultation, we identified two quarantine areas in the ward. Initially we designated one bedroom as the ‘COVID bedroom’ as well as the seclusion area as containment area as a last resort for uncooperative patients. Isolating young people in a designated bedroom without access to their parents and interacting only with fully ‘gowned up’ staff members was at times challenging. We reduced the stress by facilitating frequent contact with family members over phone or Facetime. On one occasion, a young person exited the bedroom and potentially infected the whole corridor. They threatened staff with a sharp object requiring police intervention and relocation of the young person to the seclusion room where they were nursed until the COVID test result came back negative.

It became clear to us that a single bedroom without an en-suite was an unsatisfactory quarantine area, so we switched this function to the bedroom located in the Pod area once it became available (see Chap. 2).

Personal Protective Equipment

In line with CEC recommendations and NSW Health Directive, from the first lockdown, staff and visitors were required to wear surgical masks in all clinical areas. All staff received training in the donning and doffing of personal protective equipment (PPE). When there was a suspected COVID-19 case, any staff member approaching the young person was required to wear PPE. Depending on the different levels of alert (green, amber or red) we were required to use face masks in only the clinical areas or in all areas of the Unit. In July 2021 we entered for the first time the red alert level which required the use of plastic goggles or shield (if wearing glasses) to protect from droplet transmission to the eyes. Seeing staff wearing PPE drew various reactions from the young people. There was a mix of curiosity, fear and confusion. We tried to mitigate patient anxiety through updates about COVID related matters at the community meeting. Eventually, seeing staff wearing masks and PPE became the ‘new normal’ for the young people.

Admission Planning

The first step of admission planning comprises an assessment of the young person and their family at the location where they are admitted or followed up (e.g. outpatient CAMHS) (see Chap. 4). During the initial outbreak of COVID-19, we transitioned to virtual meetings using the Zoom platform to assess the patient and their family. Unfortunately, the connection was intermittently unstable rendering the picture and sound quality poor. We found it difficult to get an accurate impression of the young person and their family, and engagement with the family was compromised. Overall, we found that for a sensitive process such as engagement and assessment, virtual technology was a poor substitute for meeting face to face. Whenever restrictions were relaxed, we have reverted to face to face assessments. The second step consists of the pre-admission meeting visit to the Walker Unit (see Chap. 4). We have continued to insist that the young person and family visit the unit in person, while observing infection control measures. On one occasion, we trialled a virtual tour of the ward, but found this method poorly suited to purpose.

The third step is the actual admission. Our procedure is to invite one parent to come to the Unit to help to settle the young person into the new milieu. We maintained this throughout the COVID-19 outbreak to reduce the stress linked to a transfer from another hospital or an admission from the community.

Staff Meetings

The hospital administration enforced a limit on the number of people who could be in the same room, based on a rule of four square metres per person. We had to rethink how to organise routine meetings such as morning handover, the case review and supervision. We transitioned to hybrid meetings, with some staff attending in person while others attended virtually using the Zoom platform. An unintended benefit was that hospital administration invested in better quality laptop computers for our staff, and upgraded the sound system in the main meeting room. In addition, staff could join meetings even if they were offsite. This was of great benefit on occasions when individuals were required to isolate at home.

School Programme

During the first lockdown, the Department of Education decided to remove the teaching staff from face to face teaching and change to online learning. As most of the young people at the Walker Unit have a long history of not attending school for various reasons, it was very difficult to maintain a structure. The allied health and nursing team ‘stepped up’ and we had rotations of different allied health members and nursing staff supporting both learning centres for two learning periods from Mondays to Fridays. After the restrictions were eased, the teaching staff was allowed back on the ward. Lessons learned from the first wave of the pandemic led to a different approach when the second wave again caused school closures. Our school principal advocated for a continuation of face to face teaching. To enable this some adaptations were required, such as using the dining room as main classroom and requiring the students to wear surgical masks. The now multipurpose area was regularly cleaned and disinfected. Another challenge arising from school lockdowns was disruption to the school re-integration process (see Chap. 7). As such, some young people were discharged without a successful re-integration, while for others discharge was delayed.

Group Programme

The Walker Unit followed the MHS advice on a risk-based approach to managing groups during the pandemic. This included identifying hazards and controls to manage COVID-19. The group facilitators took on the marshalling role, environmental management, ensuring compliance with social distancing and hand hygiene practices being followed as well as recording details of the group times and size limits to conform to the recommended limit of no longer than one hour per session.

During the outbreak in March 2020, we were restricted to no more than three students per group. To maintain continuity of the group therapy programme two small groups were run in parallel, switching over after half an hour. This was obviously much more labour intensive and not sustainable in the longer term. The other imposed restriction was that the young people were not allowed to go on group outings which made them feel even more restricted. These adaptations were similar to those reported from acute inpatient settings (Leffler et al., 2021). As an alternative to outings, we used the courtyards as often as possible to provide the young people with exposure to fresh air and sunlight. As soon as the restrictions eased after the first wave of the pandemic daily walks were reinstated. During the second wave, walks were permitted. Outings, however, have been subject to the community restrictions in force at any given time.

Individual Therapy

Each patient is allocated an individual therapist for the duration of the admission (see Chap. 10). The pandemic has had less impact on individual therapy than other treatment modalities. For some patients Exposure and Response Prevention (ERP) therapy is indicated. ERP is usually undertaken in the community but the pandemic restrictions have required us to deliver ERP on the ward.

Family Therapy

Family therapy had to be modified during the initial outbreak. We continued to see all family members in person in the first month of admission as this is the time where we connect with the family and work on the Genogram and timeline. After this initial phase we would see one or both parents in person and have other family members over Zoom or phone conference. During the second outbreak, we had the Pod area available for family sessions. Families could access this part of the facility without coming through the ward area, which was of benefit in reducing the risk of contamination. After each use, the Pod was cleaned and disinfected.

As leave with family and to the family home is an important part of the therapy process, we continued to grant leave with the precaution of families being asked not to go to any public place during the leave period in order to diminish the risk of contamination. Complications did occur when young people absconded during their leave, or self-harmed requiring attendance at their local Emergency Department. In such cases, we isolated the patient on their return to the ward until they received a negative COVID test.

Morale

The experience of the pandemic has challenged staff morale. It is disappointing not to be able to provide the full range and quality of clinical service the Walker programme has to offer. There is an ever present threat that a positive COVID-19 case among patients or staff could lead to ward closure. Constant changes in advice and procedures have been frustrating. But we are fortunate that most staff have been able to continue in their substantive clinical roles. Staff absences owing to the need for isolation have been minor. However, there remains a threat to the workforce when restrictions ease and the numbers of COVID-19 cases are predicted to rise. Informal staff interaction (e.g. staff farewells, social and morale boosting gatherings) has been restricted, but not completely eliminated. One project that has served to encourage staff unity has been the writing of this textbook.

Conclusion

The Walker team was able to continue to deliver treatment to the most vulnerable and unwell young people of the state of NSW throughout the COVID-19 epidemic and despite having had many suspected positive COVID cases, to the date of when this e-book was written we have not had any confirmed COVID cases within the patient population or the Walker Unit staff (including education department staff).

PPS

Just as the manuscript was being finalised for submission, a student nurse on placement at the Walker Unit tested positive for COVID. Within weeks several staff and patients contracted the illness. Young people who fell ill while on leave were granted extended leave to isolate at home. Those who developed symptoms while on the ward were isolated from the other patients. For a period the unit was in lockdown, with no visitation and no leave privileges.